For the Love of Nurses

I’ve always loved nurses. My mother, one of the women I admire most in the world, is one. My sister is one, too. As a doctor, I’m lucky to work with nurses every day. Unfortunately, though, in the world of electronic records and quality measurements my nurse and I work apart more than we work together.

MomNurseSoldier

My Mother at Boot Camp to Become a Flight Nurse 

Doctors and nurses make a great team, especially when left alone to simply care for our patients. This rarely happens today. Instead of focusing their full attention on patients, the healthcare team is routinely diverted to more mundane tasks like data entry, paper signing and insurance appeals. They’re still on the same team, only the game has changed. Instead of working cooperatively together, they often work separately. The team is not happy with their new role, but the one who really suffers is the patient.
I didn’t realize when I first became a doctor how much I would depend on nurses, but it didn’t take long to find out. My first rotation in residency was the terrifying Intensive Care Unit (ICU). I had no idea what to expect. I wore my pressed new lab coat with my name badge identifying me as “Doctor,” but was oblivious about my role, having never spent any time in an American hospital. The white coat I’d waited so long to wear didn’t magically instill in me the confidence I had hoped it would, like putting on a superhero cape.
In Polish hospitals where I began my training the doctor’s role was seemingly endless. Doctors did everything from taking blood pressures and temperatures to physically tracking down results (and wandering patients). They delivered medications. They drew blood. They were an integral part of every facet of patient care.
It was clear from my first day in residency that things were very different in American hospitals. A sympathetic nurse simplified my job for me, “You write orders in the chart and we follow them.” So, all I had to do was write down what I wanted and it would be done? The job was suddenly both simpler and less noble than that of the Polish doctor. What I’d soon realize was that these hospital employees who awaited my orders would be the very people I’d rely on most in the future to guide me, keep me sane and keep our patients safe.
Nurses were indispensable.
Every morning before ICU rounds my colleagues and I spoke with the evening nurses to find out how our patients had fared in the night under the half-asleep watch of the exhausted on-call resident. I discovered quickly that when I was the on-call ICU resident I should expect no sleep. Alarms beeped all night. The very act of clipping my pager to my lab coat caused my heart to pound. On the rare occasion that I closed my eyes for a few minutes, compassionate nurses gently shook me awake on behalf of patients needing immediate attention. A page from the ER meant an admission, a process that took at least an hour to complete. And when my work was done, the nurses took over.
I thought I’d be ahead of my childless peers, used to frequent nighttime awakenings from a hungry, crying infant. Unfortunately, this sleep deprivation was nothing like nursing a baby in the night. Not only were the awakenings unpredictable and frequent, but they also they required a different level of consciousness. A page from an observant nurse watching over my very sick patients required an instantaneous transformation to full daytime mental capacity. Lives depended on it. Sometimes I just stayed awake all night in anticipation of imminent disturbances from dying patients and sometimes because it was better to stay awake than be jarred awake forcibly.
In those early hours when the hospital halls were quiet and empty, I marveled at the dedication and knowledge of the nurses. When a patient took a turn for the worse and the resident ran out wide-eyed and terrified, the composed nurse made helpful suggestions without being asked. “Would you like me to draw up a little morphine, maybe just a milligram to start?” Or, slightly more urgently, “I’ll get the crash cart and call the senior resident, just in case.” They knew medicine, but more importantly they intimately knew their patients (and their family members).
When I was almost 5 months pregnant with my second son, I rotated through the Neonatal Intensive Care Unit (NICU). Some of the babies in the incubators were younger than the one growing inside me. I cradled my belly in my hands as I watched over these scrawny, hairless infants attached to tubes and wires. I looked carefully at their charts, taking note of the gestational age of all of the premature babies, which provided me an amazing glimpse of the development of my own unborn son.
I tried to comfort pale, wide-eyed mothers as they sang to their babies through the plastic incubators. I watched as fathers stroked them with gloved hands poked into a small opening in the side wall. Frequently, alarms blared and stricken parents were pushed aside by a team of providers rushing to save their baby. I wondered if I could ever be as strong as these brave parents. I wondered if I would ever be as knowledgeable as their doting nurses.
NICU babies’ lives were dependent on bed alarms, frightened residents, dedicated doctors and (probably most importantly) attentive nurses. There was no room for error, exhaustion or a bad day for any member of the team – a scary thought for a pregnant resident. Fortunately, the NICU nurses were an amazing source of expertise and strength. They buzzed around the unit averting disasters while calmly directing gaping residents how to help. They provided reassurance to terrified parents and consoled devastated ones.
When babies graduated from “critical condition” to “feeders and growers,” the nurses rejoiced as they deftly slipped their charges out of incubators and gently placed them into the long-waiting arms of mothers. When a baby was ready to be discharged home, it was the NICU nurse who taught the parents how to care for their unique needs and when to seek help.
Sadly, practicing medicine has changed a lot since my residency. Instead of working side by side with my nurse in the care of our patients, we often work independently on separate administrative tasks at our computers. Still, my admiration for nurses has grown since my early years as a terrified resident. I’ve worn the badge of doctor for more than two decades now yet I have no illusions about the critical importance of my nurse, even though our jobs are different. She stands in front of me like Wonder Woman, deflecting solicitors, angry patients and insurance company probes. She’s the first to offer comfort to my suffering patient and tells me when they need a little extra attention. She reminds me before I enter the exam room if my patient has recently lost a spouse or had a new grandchild.
My nurse is like a pressure-relief valve. She takes care of much of the bureaucratic busywork sifting through my piles of papers, filling out the parts she can and organizing them so I can take have a little more time with my patients. She knows which forms to complete out to allow my patients to stay on their diabetic medications when their insurance formulary changes. She stands by the fax machine, copies the paperwork, and triages the phone calls. She calls the pharmacist to confirm what medications my patients are taking when they forget their list. She calls the hospital to get discharge summaries and the specialist’s office to request test results. She collects the urine, swabs throats and nasal passages, bandages wounds, records the vitals and reviews the allergies. She cleans up the vomit, disinfects the room and brings my shivering patient an extra blanket. She’s the bad guy who gives the shots I order.
So, what does the doctor do? I wish I could report that while the nurse was working behind the scenes the doctor was in the room caring for the patient. Sometimes I am, but much of my time is devoted to activities unrelated to their direct care. I sign hundreds of papers each week, some in ink and some electronically. The volume is overwhelming. Sometimes the signature is on emergency room visits, test results performed elsewhere or reports from the specialist office. On these papers my signature just means “Yes, I saw this, please file in the chart.” I skim these papers (though I know I should read them thoroughly) because there isn’t enough time in the day for me to meticulously read them even if I wasn’t seeing patients. Other times I sign for medical equipment for a patient (like a wheelchair, CPAP machine or crutches) or for tests to be performed (like a chest x-ray, hearing evaluation or bone density).
But doctors don’t just sign their own papers, they co-sign written orders from nurse practitioners (who are able to prescribe drugs, remove skin lesions and do pretty much everything the doctor can do except apparently sign orders). This even includes orders from visiting nurses (for things that nurse practitioners actually did themselves when they worked as nurses) – things they are likely much more qualified to sign for than doctors.
The worse offenders of needless signature-seeking, though, are adult homes. Once a week when I see patients in an adult home I find a pile of notifications waiting for my signature. “Doctor aware of 3 pound weight loss over 6 months.” Or. “Doctor notified patient slid out of chair, no injuries.” And, “Doctor aware patient seen by podiatry and had nails cut.” Really? Yes, really.
I also fill hundreds of prescriptions every week. Nurses send them to me electronically with the dosage, amount to be dispensed and the refills. I click the button that sends them to the pharmacy. I don’t have time to verify that every detail on every prescription is correct. I look at the patient’s name (Do I know this patient?) and the drug (Does it require blood work and if so when was it last done?) and the dosage (Does it look like a reasonable dose?) and the amount of refills (Have they been in the office recently? If not I ask my nurse to call them for an appointment). If something doesn’t seem right, I open the chart and check myself. I can’t do this for every prescription. No doctor could. There simply isn’t enough time in the day to double check every chart for every medication that every patient takes to confirm that the information is accurate. I must trust that the prescriptions sent by my nurses are accurate and hope that the pharmacist will call if something isn’t right. Ultimately, though, I’m responsible.
Universal health care would likely eliminate much of this unnecessary paperwork, freeing up the healthcare team to do what they do best – taking care of their patients. Most doctors I know would much rather spend less time on the computer and more time talking to and caring for their patients. Doctors want to jump off the administrative hamster wheel where they work hard to get nowhere.

But they would still be running in place if it weren’t for their nurses.

A distressed friend called me recently. Her child was in a local hospital and she worried about whether it was the right place for her. “Her nurse is wonderful, though” she confided.
“A good nurse is actually the most important thing,” I told her. “But don’t tell her doctor I said that.”

Advertisements

Public Health Notice: Guns Actually Do Kill People

I tried not to let my boys play with toy guns when they were little. I soon discovered, though, that in a young boy’s imagination everything became a gun – a stick, a rolled up newspaper, a pointer finger. Defeated, I slackened my efforts. I still didn’t buy them toy guns, but I stopped reprimanding them for creating their own (although I couldn’t quite hold back from telling them that they were shooting “kisses”).

I was stung when a young mother ushered her son away from my sweet and sensitive little boy at the playground while he quietly played on the wood chips with his beloved green army men. “We do not play violent games!” she whispered with urgency, loud enough for us to hear. She glared at me as she yanked him away from us. My son looked up at me apologetically. I shrugged my shoulders and smiled what I hoped was a reassuring smile, but I shared in his hurt. I was far from pro-gun but even on the playground over a dozen years ago our country was divided.

IMG_3176

Buddha and Green Army Men doing Yoga Poses

As they got older, I kept my boys away from violent video games as long as I could, gently guiding them toward more creative endeavors. We didn’t get any TV stations so they only watched the videotapes we brought home. Violence didn’t enter our home with the evening news. It still came, though.

I remember my horror when I overheard my kindergartener (who was running in the grass “flying” a little toy airplane) say “Crash! Boom! Twin towers fall!” After much internal debate I had decided not to tell him about 9/11.  I thought I was doing my job as a parent, shielding him from the scary things in the world. I couldn’t protect his innocence when he was at school, though, even at his tender age. At least I didn’t have to worry about school shootings back then.

But today (despite still having no television stations) there is no escaping the violence. It flashes on the computer and cellphone. My watch vibrates in alarm with each horrific headline.

In truth, I’m not entirely anti-gun either. I live in upstate New York where some of our local schools close for the first day of hunting season. My own little dirt road probably boasts dozens of guns, some in my own home. I’ve shot skeet (poorly) and aimed hunting rifles at targets in my yard. It’s loud and jolting and not really my idea of fun. I’d rather dangle my feet in the stream and watch the frogs.

JenCrossbow

Attempting to Use a Crossbow

Sometimes my neighbors hunt with old-fashioned muzzle loaders and sometimes with compound bows. It’s part of the challenge. They track their prey and bring it home for dinner. They aren’t hunting with semi-automatic weapons or handguns.

I’m a family doctor in a rural town. Many of my patients are avid gun enthusiasts and some are surely active members of the NRA. Some of my patients are ardent pacifists too. Most probably fall somewhere in the middle – they own guns for hunting or encourage their neighbors to hunt their property to cut back on the deer population that thrive on their lush gardens.

Because I’m a doctor, though I can’t ignore the health risks posed by guns. Guns (by their very nature designed to emit projectiles at high velocity) are dangerous. So are motor vehicles driven erratically or at high speeds or by people not licensed to drive them. This doesn’t mean guns should be banned but (like cars) there should be stringent rules to ensure their safe use by qualified people. 16 year old novice drivers should wear seatbelts and obey the speed limit. They shouldn’t drive motorcycles 100 miles an hour without a helmet.

They also shouldn’t have access to high power weapons that fire as fast as they can pull the trigger.

After the most recent school shooting in Parkland, the American Academy of Family Physicians (of which I’m a proud member) joined with the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Psychiatric Association to plead (again) that America treat the epidemic of gun violence as it would any other public heath problem – identify risk factors (through extensive research of fatalities) to take steps to prevent future deaths.

Because gun violence isn’t just about mass shootings. Both suicides and unintentional injuries are on the list of the top 10 causes of death in this country. Having a gun in the home increases the risk of both suicide and homicide. The American Public Health Association and the American Medical Association label gun violence a public health problem. Yet there is minimal research on gun violence. Why?

America used to study gun violence. In 1996 the NRA lobbied Congress to pass an amendment to prevent the Centers for Disease Control (CDC) from using money for researching gun fatalities. To be clear, the CDCs purpose is to study causes of death to help prevent future ones. While they are best known for studying diseases, they also study car crashes, drownings, falls, traumatic brain injuries, suicide and more. Guns are involved in approximately half of suicides in this country and yet this amendment effectively restricts studying gun ownership as a risk factor.

The stated intent of the 1996 amendment was to forbid politically motivated research. At the same time it was passed, though, Congress lowered the CDC’s budget by the exact amount it spent on this research. In 2016 over 100 medical groups wrote a letter to Congress urging them to repeal this amendment. Even the former congressman who originally sponsored the bill requested it be reversed. In 2018 the law still stands.

The refusal to even look into gun ownership as a risk factor for death is akin to children refusing to acknowledge bed time – squeezing their eyes shut tight, plugging their ears with their fingers and shouting loudly to avoid the bad news. As if not acknowledging it might make the truth go away. That guns are dangerous. They can kill people, intentionally or not.

But guns don’t kill people. People kill people. The problem is the mentally ill.
Oh, if only it were so simple! But, the data doesn’t support this. If this were true then America would have more mental health problems than other countries (it does not). Also, countries with higher suicide rates (and therefore presumably more mental illness) would have more mass shootings (they do not). Clearly anyone who shoots innocent people is not well, but a crazy person with a knife or golf club can not inflict the same damage.

Nope. It’s about access to guns. Around 40% of Americans claim to live in a household where there is a gun. We make up less than 5% of the world’s population and boast 42% of the world’s guns. And, surprise! The United States has the highest rate of murder by firearm in the developed world.

It would appear that the guns themselves are the cause of the violence.

Well, if guns are the cause of all these school shootings, we should just arm the teachers. While an attractive theory, unfortunately adding more guns is not the solution to gun violence. Police and military personnel spend an enormous amount of time training with guns and running active shooter drills. Repeatedly. Despite this, even the professionals aren’t immune to gun deaths. An FBI study of active shooter incidents from 2000-2013 showed that police who engaged the shooter had casualties of almost 47%.  Nearly half! In the highly emotional chaos of a school shooting, a police officer protecting the innocent might shoot at anyone wielding a gun (including teachers).

To assume that simple training on the basics of handling a gun will make schools safer is like believing that a few hours in the car with your teenager will make them ready to race along a freeway in rush hour. I certainly don’t want to be in that car.

The fact is that people don’t behave predictably or reliably under stress. It’s biological – the body’s reaction to danger is fight, flight or freeze. While we’d like to think that in an emergency situation we would fight (or at least run), many of us freeze. This is especially true when the danger involves people we care about (and the teachers I know care deeply about their students).

Despite 11 years of schooling and 18 years in practice, when a medical emergency happens involving my own family I freeze (and cry while my husband takes over). When my mother was choking a few years ago, I panicked. Years of training in Basic Life Support and Advanced Cardiac Life Support (with recertification every 2 years) vanished. I froze and watched her helplessly. When my son had a febrile seizure in our car, my Pediatric Advanced Life Support certification was useless. I grabbed him from his carseat and ran barefoot down the highway waving my arms frantically until someone stopped. This is not the expected behavior of a highly trained professional.

I’m sure some teachers would be able to handle a weapon in a crisis. When my husband was a teacher, he would have done just fine. Me, not so much.

After every mass shooting The Onion runs an article with the headline “‘No Way to Prevent This’ Says the Only Nation Where this Regularly Happens”. So, what can we do? For one, we could look to other countries that have successfully tackled this very problem.

In 2013, the United States had nearly 33,000 gun-related deaths compared with 13 in Japan (a country with a third of our population). Americans are 300 times more likely than the Japanese to die by a bullet. Our gun ownership is 150 times as high. The gap between these numbers suggest that owning guns is not the only cause. The other crucial factor is gun control legislation, which tends to reduce gun murders (according to a recent analysis of 130 studies from 10 countries). Ours is weak, Japan’s is strong.

In Japan, citizens who want guns must attend an all-day training class, pass a written exam and shoot with 95% or higher accuracy. They must also pass a mental health examination and have a background check including interviews of family members and friends. If they pass these rigorous tests (which must be taken again every 3 years) they are limited to purchasing shotguns or air rifles. Tighter regulations keep guns in the hands of those proven competent to use them.

In some countries, governments bought back guns from their citizens in an effort to curb gun violence.  The result?  Gun-related deaths plummeted. After a gun buy-back program in Australia, gun deaths were cut in half. In the UK, (where the government also banned handguns, semiautomatics and pump-action firearms and required shotgun owners to register their weapons) this number dropped to 50-60 gun deaths a year.

But the American people don’t want gun control legislation!
According to a recent Gallup poll, the majority of Americans are unhappy with current gun laws and policies with most in favor of stricter legislation. A more accurate statement might be that the NRA doesn’t wan’t gun control legislation as demonstrated by the approximately $3 million spent each year to influence policy (not including millions spent supporting political candidates that oppose gun control).

But what about the 2nd amendment?
At the time the Constitution was signed state militias (comprised of able-bodied white males) were conscripted in order to suppress slave and anti-tax insurrections and to fight Native Americans. These were trained and disciplined men. The phrase “the right of the people to keep and bear arms” referred to this “well-regulated militia” and likely wasn’t meant to include individual citizens.

Even if the founding fathers did believe that individuals had the right to own guns to protect themselves from an over-authoritative government, is this even applicable today? Is an individual really going to stand up to the government with a gun? I doubt any citizen (or group) would be successful challenging our modern military’s precise and expensive firepower and surveillance capabilities not to mention extensive training. Most citizens don’t hone their combat skills with the vigor of the armed forces who train to protect our country.

Parkland students who have voiced their concerns over gun control have received death threats. We should be much more concerned about their 1st amendment right to freedom of speech.

It’s simple. To live peacefully in society, there have to be rules. Many, many, many things in our country are regulated by our government including motor vehicles, fireworks, alcohol and tobacco. The regulations are generally reasonable (for example, you must be a certain age and pass a test to apply for a driver’s license and when driving you must obey safety rules like stopping for people walking in a crosswalk).

The epidemic of gun violence puts Americans at risk every day. Protecting the lives of our young people (and all citizens) must take precedence over interpretations of Constitutional rights.

What kind of gun control rules are we talking about?
Most of the proposed rules are actually pretty logical. Reasonable restrictions include rigorous background checks to prevent perpetrators of domestic violence from wielding weapons against their victims. They also include not allowing the sale of weapons to the mentally ill or to people not old enough to drink alcohol. They include waiting periods for purchasing handguns which could potentially save lives by preventing impulsive suicides.

Gun violence has become more deadly in part due to the lethality of the weapons used. The United States should ban adaptations that convert semi-automatic guns to automatic. After all, we don’t allow our citizens to carry grenades or launch missiles (or even purchase most fireworks in my state).

On February 16th, the American Academy of Family Physicians once again urged the President and Congress to take firm action against the public health epidemic of gun violence in 3 simple steps:
▪ Label gun violence as a national public health epidemic.
▪ Fund appropriate research at the CDC as part of the 2018 federal budget.
▪ Establish constitutionally appropriate restrictions on the manufacturing and sale, for civilian use, of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity.

I applaud these sensible recommendations.

Even my gun-loving neighbor would agree to them.

 

Make America Good Again

The first thing Paul did when we moved into our home in upstate New York over 17 years ago was to take down the satellite dish from the barn roof. We had chosen a home in the woods at the end of a dirt road because we wanted to experience nature. The dish was horribly out of place. Besides, we’d already decided we didn’t want television programming in our lives anymore.

The choice was not made out of a radical opposition to television as a symbol of society’s evil, but as a personal choice about what was important to us. Television shows simply sucked away too much of our precious and limited time. We wanted to do something rather than watch something. As a reminder of our commitment Paul carved “Don’t just sit there” and “Go do something” into the cabinet doors he made to contain our TV and video player.

I grew up with a TV in every room. While we didn’t actually eat in front of a TV, there was one in the kitchen that often served as background noise while we ate. On the rare occasion I found myself alone in the house, I turned on multiple TVs for company. I felt better with the noise. As I got older, though, I found more comfort in silence.

My family hasn’t withdraw from society entirely. We have a DVD player to watch movies and (eventually) the most popular television series at our convenience (usually months or even years after the rest of America). Because of our remote location we don’t receive signals for any stations at all, not even local ones. Unwanted commercials and violence are not automatically granted access into our home. I‘ve seen very little footage from recent natural disasters, mass shootings or terrorist attacks, which suits me fine. I don’t want those images imprinted in my memory.

Of course we sometimes miss television, especially when major world events occur (like 9/11 or the 2016 elections). We can’t even stream news because of extremely limited satellite Internet. When big events happened, Paul would make rabbit ear antennas out of bent clothes hangers, tinfoil and pieces of wire with minimal success. Now that the TV is digital this no longer works. For me, living in my occasionally frustrating but mostly peaceful self-imposed bubble is a worthwhile sacrifice for the insulation it provides from the horror of the daily news.

It’s really is no big deal. I don’t even remember I’m without television stations until it comes up in conversations to the shocked disbelief of a friend (Did you see the grand finale last night?) or a patient (Can I try the drug from the commercial with the people singing on the boat?). For a short time when my sons were young I worried they might feel excluded from culturally relevant conversations because of their lack of exposure. Then one day before Christmas they visited their grandparents and we had instant confirmation that we’d made the right choice.

Paul and I picked the boys up after shopping and bundled them into the car under a barrage of shouting over each other. I want the robot that walks! I want a razor scooter! I want G.I. Joe guys! I want a Transformer Go-Bot! I want a Game Boy with Pokemon! Paul and I stared at each other in disbelief. Our sons, who could easily busy themselves with a stick outside for hours, were screaming about what they believed they now needed to make them happy. In an instant they were transformed from content children to desperately deprived ones.

I believe most Americans can relate to how they felt. When I’m at a hotel or visiting friends and family with TV I’m quickly overwhelmed with the amount of channels alone. There are so many choices that I struggle to find a single thing I want to watch. When I finally settle on a show, I worry I’m missing something even better on another channel and start flipping again. And, I want the things in the commercials – the beautiful boat, the ocean cottage and the glamorous silky black dress. This is the paradox of choice. The more we have, the more unhappy we are about what we might not have. We develop FOMO (the very fact that this is a term for Fear Of Missing Out shows how widespread this phenomena is in our society of abundance).

As a child in Poland, Paul was happy to get an orange of his very own for Christmas. Once his family immigrated to America, his father bought practical and inexpensive gifts for his children, like a pen or a book. This was the norm, so no one felt like they should have gotten more. Christmas in my middle-class American home was the opposite. It was an extravagant abundance of unaffordable gifts, a tradition I have continued (often to my own dismay) with my sons. I wanted them to feel the same magic I felt every Christmas morning. The intensity of my desire to share this with them this won out over Paul’s more reasonable Christmas day visions.

We did succeed in making Christmas magical but while I thought it was all about the presents my boys taught me it is actually about the traditions. They notice if I don’t display every ancient Christmas decoration. There’s an uproar when Paul tries to throw away a ratty old plastic ornament. Though my oldest can legally drink, he still shakes his gifts to find out which one has the lego set. He tears it open and puts it together before we even have breakfast.

The magic of the season is in the multi-course slavic Christmas Eve feast we share with Paul’s family. Paul’s mother spends the week before Christmas in the kitchen preparing traditional fish dishes, borscht with mushroom dumplings, and cakes. For the last two years my sons have helped her to make hundreds of pierogis just before the big night. We toast each other with vodka and pickled herring. We share wafers blessed in the Polish church, each person breaking a piece off and giving it to every other family member along with kind words and wishes.

The magic is in the big Christmas breakfast served on good plates with gaudy Christmas tree napkin holders, gingerbread placemats and jumping reindeer candlesticks. It’s in setting an extra place at the table so an unexpected guest might feel welcome. It’s in piling in the car afterward to drive for hours to be with their cousins.

I don’t need to look far for excess in my own life (just ask Paul, who is constantly trying to simplify). Every change of seasons I lug bins of my clothes in from the barn storage. I take the summer clothes packed tightly together out of my closet to make room for the winter ones. As I fold each unworn item and cram it into the bin I wonder why I can’t just donate most of them to Goodwill. Why am I holding on to this bright orange shirt from college? Will I really ever wear these pants that are too short? The skirt made from scratchy material? The dress that is too tight or the one that has needed a button sewn on it since last summer?

The truth is, I wear the same comfortable handful of shirts and pants every week. If anyone paid attention to my wardrobe (which I’m fairly sure they don’t) they’d think I owned very few instead of the over-abundance of neglected clothing that spills out from my closet. I rarely wear dresses (because I can’t wear sneakers with them) and yet I have a closetful of beautiful dresses. When I need to dress up, the choice is overwhelming and I choose the same comfortable one again and again.

Why is it so hard to get rid of my clothing (or my unmatched mugs and plates and pots and pans and board games not played and books I won’t read again and snow pants that no longer fit my sons and threadbare sheets and clutter that needs to be moved around every time I clean and that doesn’t add to the beauty or joy of my home)? When I die I don’t want my sons to sort through mounds of things I’ve collected in my pursuit of happiness (or at least the false assurance that I have enough). I want to be more like my sister Ally. If you tell her you like her sweater, she takes if off and gives it to you. I want to be able to give away the things I cherish but don’t need or use to someone who needs it more.

Paul and his sister traveled back to Poland when they were in college. They took a train from Warsaw to the small town where they’d lived with their parents and grandmother before immigrating to America. Paul was hungry so he rifled through his bag until he found a banana. As he set it on the small table in front of him he noticed that the old farmer and his wife sitting across from him were staring at it intently. They spoke rapidly in whispered voices to each other, stealing glances at the fruit. Finally Paul spoke to the old man in his elementary Polish. He learned that the farmer hadn’t eaten a banana since he was a child. He hadn’t eaten a banana since he was a child. He hadn’t even seen one, such were the scarcities in Poland.

Paul held out the banana to him. At first the farmer declined, shaking his head vigorously. The gift was too generous. Paul was persistent until finally the old man relented. While the farmer lovingly pealed the banana his eyes filled with tears. His wife reached over to steady his shaking hands as Paul and his sister watched in awe. The farmer smiled, his mouth full of banana, and offered Paul a sip from his thermos. Paul moved next to him and shared his vodka for the remainder of the trip.

It’s hard for me to imagine this kind of deprivation. The pure joy in farmer’s face shows how happy people can be with so little. Many war-torn and developing countries suffer far greater hardships than most Americans will ever know. To suggest to a hungry foreigner that we need to “Make America Great Again” must not only seem absurd, but like a slap in the face.

The desire for more and bigger and better is the cause of much unhappiness globally. Weaker countries scramble in a desperate attempt to hold onto what they have while bigger countries try to steal it. On a smaller scale, the beautiful pictures and posts of our friends and family on social media has an immediate effect of causing us to wonder if we have enough, if we do enough, if we are enough. We are happy for them even as FOMO creeps in.

“Make America Great Again” implies that our country is not still great. This brilliant campaign slogan appealed especially to baby boomers who grew up in the 1950s, when America was apparently a great place to live. The economy was booming. Consumer goods were abundant and affordable because wages were high and unemployment was low. America was great. Unless you were black. Or you were a woman with bigger dreams than keeping house and staying home to raise a family. Or you were (gasp) gay.

And although the 1950s did herald many advances in medicine (like the polio vaccine and pacemakers), the mortality from heart disease and cancer rose more than 50% because of rampant smoking. With the development of new lifesaving drugs also came more frequent use of addictive tranquilizers, known as “happy pills.” The mentally ill languished in understaffed and underfunded asylums while epileptics were sterilized and underwent lobotomies. Not so great.

Americans need to change their expectations. If you are lucky enough to have a steady job, food to eat and a safe place to live then this is truly something to be grateful for. The wild pursuit of more and better is exhausting. Acquisition doesn’t lead to happiness. It just leads to the desire to acquire more. When we complain about the good old days (that really weren’t all that great for many Americans) to someone whose next meal is uncertain, we sound like whiny, spoiled children. Instead of lamenting, we might explore how we can help our less fortunate brothers and sisters. We could be kinder to one another.

We don’t need to Make America Great Again, because it already is.

We need to Make America Good Again.

XmasBedPhoto2017

Christmas 2017

Open Arms: Immigration

If you’ve tried to schedule a physical exam with your doctor recently (or worse, tried to establish care with a new doctor) you probably had to wait a while for an appointment. Sometimes months.

If you called your doctor’s office because you had a sinus infection or the flu, chances are you were told that your doctor’s schedule was already full. If you were lucky, you were offered an appointment with another provider in the office but probably you were directed to your nearest urgent care.

That there is a shortage of general practitioners in this country is unlikely surprising. You have experienced it. And, its only going to get worse.

Many more US medical school graduates become specialists than foreign-born doctors in part because specialists are paid up to 45% more than general practitioners. This doesn’t mean that doctors who choose to specialize are greedy. Studying medicine is an expensive investment (except in countries where education is free).

And the cost is not just financial. Becoming a doctor is a lifelong learning commitment to a demanding job in a hostile healthcare system. For some, the costs simply outweigh the benefits. The result is not enough native-born doctors to meet the growing demand for primary care. This gap in care is partially plugged by foreign-born doctors.

Immigrants.

Immigrants make up more than 1/4 of US physicians. They are a major part of the solution to the primary care shortage problem.

After the travel ban was instituted, American Academy of Family Physicians president John Meigs, MD wrote a passionate letter to the president. I was proud to be a member of the AAFP as I read his words. We are writing to express the importance of this nation continuing its historical tradition of welcoming immigration and the talent and energy these individuals bring to this country. The AAFP promotes and advances the work of family physicians from all religions, races, ethnicities and cultures in the United States and around the world.

Dr. Meigs’ words echoed the sentiments of many family physicians. As an organization, we are adamantly opposed to discrimination of all types, including policies that identify or isolate individuals based on their gender, religion, ethnicity, nationality or geographic location.

The conclusion of his letter could have been written about any profession. Fully engaging all talent and expertise in the healthcare community leads to better health outcomes, diversity in medicine and should be encouraged.

Diversity in medicine should be encouraged. In truth, diversity in everything should be encouraged. Immigrants like Albert Einstein (who came to America during the Nazi occupation) and former Secretary of State Madeleine Albright (who immigrated from Czechoslovakia to flee a Communist takeover) bring diversity that makes this country competitive, colorful and vibrant.  Americans love Thai food and Chinese New Year celebrations. We like to grocery shop in Little Italy and buy Guatemalan handbags and Mexican glassware.  We love diversity.

Immigrants also bring beauty to our country.  John Muir, world-famous naturalist and the “Father of Our National Park System,” was an immigrant from Scotland.

That’s correct. An immigrant is largely responsible for the preservation of the beautiful spaces America treasures.

Unless you are a native American, your family immigrated here. Just ask any elementary student. I remember when I was a little girl that I was so proud to live in the country that took in the tired, the hungry and the poor. I believed in the magic of the melting pot.

And, if I hadn’t met and fallen in love with an immigrant, I might not have ever become a doctor.

I didn’t win a coveted spot in an American medical school when I finished college. Competition was fierce. My mentors encouraged me to try again next year. But I had no interest in finding a job in the allied health field to gain experience and make connections like many aspiring medical students. I had bigger plans for my life. I didn’t just want to be a doctor, I wanted to be a mother. I felt a sense of urgency in my career choice. It was now or never.

So, when I was accepted by a prestigious medical school in my future husband Paul’s homeland, we decided to go for it. It was one of the best decisions we ever made.

Almost 2 dozen years later, just after the travel ban was announced, Paul posted a photograph of his family on the anniversary of their immigration. He wrote: Thank you for taking us in America. I am forever faithful and grateful. One of the first comments on this post read “At least you did it legally.”

I was furious. How do you know?  I wanted to write. Perhaps it was based on the known merits of his high-achieving family. Perhaps the assumption was made because of the color of Paul’s skin. The truth is never quite so black or white, though.

Paul’s family came to America when life was becoming increasingly difficult in Communist Poland. There were strikes and long lines for food. There was a constant threat of violence and rumors that it would only get worse.

Paul’s father Piotr dreamed of a better life for his family. His mother Irena struggled with the decision. She didn’t want to leave her big Polish family and worried she might not see them again if she did. She had a sister, though, who already lived in America and offered to help. When Irena’s mother encouraged her to join her homesick sister she finally felt free to go.

A lot of pieces had to fall into place before they could make such a dream happen. First, they had to get passports out of the country, which was not easy. Many people they knew had been repeatedly refused. Piotr believes that they were able to get their passports because of family connections to The Party, issued strictly on the condition that they would return. They had to pretend to be just visiting America.

Next, they had to borrow money from impoverished family members to purchase the small apartment that they were leaving behind. Paul’s family of four shared this apartment with Piotr’s mother. There were 2 small rooms, one for the children and one for the grandmother. Paul’s parents slept on the couch. Piotr worried that his mother would be forced out of the apartment if they didn’t return.

Finally, Irena’s sister had to buy all 4 plane tickets in cash with American dollars. It was the only way to secure a spot on the chartered plane. The tickets were round trip, though they had no intention of returning.

Only 3 people knew of their intention to immigrate – Paul’s parents and Irena’s sister in America. Paul didn’t even know that they were going “to visit” America until the night before they left. It was too risky to tell the children ahead of time, too easy to destroy the carefully laid plans. Paul raced to the playground to tell his friends that he was leaving for America tomorrow. No one believed him.

I can’t imagine how his parents felt, full of hope and fear, when they boarded the plane with just a few treasured belongings. They must have been overjoyed to be given a shot at the American dream.

Paul’s family moved in with Irena’s sister and her family of 5. Eventually, they applied for political asylum. Eight year old Przemyslaw (renamed Paul) started school unable to speak a word of English. (Now he corrects mine.)

Porazinski Immigration

Paul’s Family just before immigrating to America

If Paul’s family had waited much longer, they wouldn’t have been able to leave. Not long after their arrival in America, martial law was put in effect by the communist government. Military vehicles surged onto the streets and the borders were sealed. Phones were disconnected (and later tapped). Mail was censored. School was suspended while teachers were questioned about their loyalty. Those found to be sympathetic to the resistance were fired.  Media, transportation, healthcare, public services and factories were put under military management. Military courts bypassed the normal court system to imprison the opposition.

If I lived with my children in an oppressive, potentially violent society with no guarantee of our next meal, I expect that I would do whatever it took to get my children to safety.

What parent wouldn’t?

Countless parents fled such regimes to the safety of our country, many without the connections and luck that Paul’s family had. These parents now live in fear that the children they thought they had saved could be sent back to a homeland that they don’t remember. Children who were brought to America with hopeful parents looking for a better life. Children like Paul and his sister.

Like many Americans, I am outraged by the threatened deportation of DREAMers. These are the children of undocumented immigrants, many with no memories of their “home” country. Some speak only English and had no idea that they were undocumented until they applied for college.

And they weren’t just granted a free ride here. DACA (Deferred Action for Childhood Arrivals) status isn’t cheap and strict criteria must be met, including a willingness to go to college or serve in our military. Those who meet the rigorous requirements and background checks are given a 2 year deferral, a dream, to stay and earn their citizenship.

I know I am lucky to have been born in this county, yet I believe these young Americans, raised among us, are every bit as American as I am.

So does former President Obama. In speaking of the threat of deportation of DREAMers he said:

What makes us American is not a question of what we look like, or where our names come from, or the way we pray. What makes us American is our fidelity to a set of ideals – that all of us are created equal; that all of us deserve the chance to make of our lives what we will; that all of us share an obligation to stand up, speak out, and secure our most cherished values for the next generation. That’s how America has traveled this far. That’s how, if we keep at it, we will ultimately reach that more perfect union.

Universities agreed, citing DACA beneficiaries as outstanding students whose presence enriched the learning environment for all students. Dozens of CEOs (including Apple, Microsoft, Amazon, Netflix, AT&T, Wells Fargo, Facebook, and Google) also joined the protest. As it turns out, 3/4 of the top 25 Fortune 500 companies have employees who are DACA recipients.

Why are we so eager to deport these young people? Children (and grandchildren) of immigrants were likely raised with stories of deprivation. Like Paul, they were taught to appreciate their chance at the American dream and the importance of living up to the privilege of living here.  Jonas Edward Salk, who developed the polio vaccine, was the grandchild of Eastern European and Russian immigrants. Henry Judah Heimlich (of the Heimlich maneuver) was the grandchild of Hungarian and Russian Jewish immigrants. Sanjay Gupta, American neurosurgeon and media reporter, is the child of Indian immigrants. Imagine if we had never let these families in (or kicked their children out)?

And yet the future is still uncertain for these young undocumented people.

Meanwhile, our country is becoming increasingly hostile. American citizens are harassed as rumors circulate about people rounded up at their work and homes. My friend’s American family carries identification because, despite being citizens, their ethnic appearance has caused them to be questioned. Their children are directed to come straight home after school. People are scared.

This summer my husband and I decided to go to Canada for our annual birthday bike trip. We were driving in New York along the St. Lawrence river when we came to a roadblock.

A heavily armed man in army fatigues stepped up to our truck. Another armed man, pulled by a lunging German Shepherd, walked around the back and peered into our truck bed. Although we had nothing to hide or fear (we were American citizens in America, after all), I felt my heart quicken.

“What is your relationship?” the man who approached our vehicle asked with a smile.

“We’re married,” Paul and I answered in unison.

“Are you American citizens?” he asked.

“Yes,” we both answered together.

He looked through the window into the back seat of the truck which was piled high with our biking gear.

“Born and raised?” he asked.

“Yes,” I answered quickly.

“No,” said Paul.

I swallowed hard. Did it matter? A year ago I wouldn’t have thought so. But a year ago we probably wouldn’t have been asked.

“Are you naturalized?” he asked Paul. Paul nodded.

“Where and what year?” he asked, his smile fading.

“Hartford, Connecticut,” Paul answered. He stumbled on the year.

I held my breath and then blurted, “1977, right?” When Paul didn’t answer right away I continued, “You were eight, I think. What year was that?”

The pause was infinite.

Eventually, border patrol let us go. We were American citizens, after all.

As we drove away, though, I couldn’t help feeling uneasy about the whole exchange. Shouldn’t the interrogation have ended when we confirmed that we were American citizens? Since when did it matter if a person was “born and raised” here? And, what if we were not white? Might we have been detained longer? Asked to show proof? Had our vehicle searched?

IMG_E3383 (1)

Birthday Bike Trip, Canada 2017

We can’t be lulled into passivity. Even if you are not married to an immigrant, even if your doctor is not a foreigner or foreign-trained, even if you don’t think you even know any immigrants because you live in a homogenous, non-diverse community – make no mistake. You will be impacted by anti-anything-that isn’t-American legislation.

Hopefully the impact will just be a nuisance, like difficulty traveling to another country (or even in your own if you aren’t white or have an accent). Maybe you’ll have to pay more for domestic fruits when there aren’t enough workers to pick it. Maybe you will have to wait a year to schedule a doctor’s appointment. It could be much, much worse though.

When we push away other cultures and and turn our backs on our neighbors we are not just hurting them, we are hurting ourselves. We are creating a deep wound in our society when we speak of building a wall or deporting young adults. When we allow the pardon of a sheriff renowned for racial profiling and violence we are sending a message to Americans (and to the rest of the world) that we accept bigotry and hatred.

When we react to each horrific act of terrorism by blaming an entire population (or dehumanize the perpetrator by labeling him “an animal”) we most definitely are not making America safer. We are furthering a division that, in small and terrifying pockets, may lead to extremism and actually cause terrorism.

I am a primary care doctor in a mostly white, rural community with relatives who arrived on the Mayflower. Yet the impact of anti-immigration and anti-anything-not-American on my own small life can’t be denied. I suspect if you look deep enough, you will discover that the impact on yours can’t be either.

I don’t want to live in a black and white world when I could live in rainbow.

 

 

 

 

(Could Easily Have Been) Me, Too (and Every Woman I Know)

IMG_4253

16 year old me

I felt the force of the “Me Too” posts last week like a punch in the chest, the volume knocking the wind out of me even as I knew in my heart that the true count was much higher than those courageous enough to speak out publicly. She’s the woman who didn’t smile back when you passed by her this morning, the elderly widow next door living alone with just her sad memories, the timid girl who gently placed the eggs in your shopping bag. She is your sister, your daughter, your grandmother, your best friend.

How do we right a wrong so engrained in our culture? How do we find the courage to demand respect for others, for ourselves? How do we remember to treat all people, even those who anger, annoy or disgust us with kindness? We can never really know the burden people carry, the sorrows burrowed deep in their hearts.

If you are a woman, you expend an exorbitant amount of psychic energy every day on your safety, even if you’re unaware of it. I know this because, despite my lifelong denial that anything truly terrible will ever happen to me (not me, too), I look around before walking into an empty parking lot. I don’t walk alone at night if I can avoid it. I check behind me before going down a long hallway to a public restroom. I even check the back seat of my car sometimes before I get in. Unfortunately a woman’s instinctual caution in public won’t protect her from the people well known to her in private.

Americans have no problem righteously condemning the burka, adorned by women in “backward countries” to shield her husband’s property from wandering eyes. We are much less vocal, though, about speaking up and acknowledging what’s happening in our own country, where three women are killed every day by domestic violence. Every day.

But violence and sexual harassment are only an overt part of the problem. The mistreatment of women is often more insidious. So much so that we often don’t notice it and when we do it’s easy to ignore. It’s not getting paid as much as a male colleague doing the same job. It’s not being hired in the first place out of fear that an internal clock will eventually lead to maternity leave. It’s preventing access to birth control in a society that still blames the pregnant girl alone for the predicament she’s in.

I am hopeful that the intolerance of intolerance that ignited the pussy hat campaign was just a flicker in an outrage inferno. It’s not that hard to publicly object to a man of power openly degrading women, though. It’s much harder in the private arena. Even women are silent about other abused women, even when they are the people they love.

Anne, a young patient of mine, revealed to me once that her mother actually entered the room where molestation (by another family member) was occurring to retrieve something she had forgotten. The mother got what she was looking for and left. She pretended not to see, guarding her heart against what was happening right in front of her. I grieve for Anne, but also for her mother who must have suffered her own trauma long ago.

I think back in shame to my own college years when someone I love dearly confided in me that she was raped. I remember admonishing her for leaving the party with that man in the first place. As if making a bad choice was a good enough reason for her violation. As if it couldn’t have just as easily been me, too.

Most of my women patients with serious mental health issues eventually share with me a dark story that changed the direction of their life, that robbed them of the person they may have become. Often these assaults occurred when they were young, stealing their childhood innocence, shattering trust for a lifetime. These life-changing events can happen so casually. No one is immune.

One weekend when I was in high school and my parents were away, I invited some friends to sleep over. The night began innocently enough. We pretended we were grown-ups living in our own home, making dinner together. Later that evening we wanted to make popcorn and watch a movie, but realized we had no popcorn. We decided to walk to the convenience store. It was a few miles away and we would have to cut through woods and several neighborhoods to get there. But it was a beautiful summer night and we welcomed the adventure.

On our way to the store we heard the thumping of loud music. Of course, we had to investigate. There was an adult party happening in one of the homes on a typically quiet suburban street. Guests spilled out onto the manicured lawn behind a white picket fence. Feeling a little mischievous, we planned to walk right in as if we were guests. Heads held high, looking much more confident than we felt, we opened the gate. Just like that, we were in.

We wandered around the party, sipping drinks and eating food as if we belonged. Soon my friends and I were separated, dispersed in the raucous crowd.

I took my empty plastic cup back to the spiked fruit punch for another refill. A polite young man offered to pour it for me. Soon we were deep in conversation. He was at least ten years older than me and I was flattered by the attention. When he asked my age I lied and told him I was eighteen.

He then asked me if I wanted to see his new car. I declined, repeatedly. After a few more drinks with him, though, I finally relented. He seemed like a nice guy and I was fully confident in my adolescent judgement. Nothing would happen, not me.

He led me out the front door and down a dark side street. I was a little shaky, but figured it was just nerves and the spiked punch. As the noise of the party receded, I began to wonder if he even had a car. I was relieved when he finally stopped in front of a low-riding sports car and opened the door to show me. He jumped inside and motioned me in. I politely declined, my friends were probably looking for me. He was persistent. I didn’t want to be rude and I most definitely didn’t want him to think I was just a dumb kid so I climbed in next to him.

He reached under his seat and pulled out a small case. I felt a fluttering in my chest as he opened it up. When I peaked inside, I was confused by a mass of pipes and tubes and glass containers. I had no idea what I was looking at. He patiently explained the various drug paraphernalia. He was in rehab, he confided. He used to do a lot of drugs but he was clean now. I thought back to all the drinks he had when we were talking by the punch. Don’t people in rehab avoid alcohol? I suddenly wanted to run. I broke out in a cold sweat.

“Let me take you for a ride,” he said. My heart pounded in my ears so loudly that I was afraid he could hear it too.

I stammered excuses. My friends were waiting. I had to be somewhere. We were just stopping by the party but had plans and it was time to go.

He put his key in the engine anyway.

Just then I noticed that the inside door handle on my side was missing. I turned back to him, unable to hide the terror in my eyes. He reached for the lock on his door. I reflexively reached out the window and grabbed my outside door handle, just as the window started to go up, just as the lock snapped down. I pushed hard and to my great relief the door opened. I jumped out. I freed myself just in time. I heard him cursing as I ran from the car back to the party.

For years I was embarrassed about my stupidity that night. I look back now, though, with compassion at my younger self. If I could’ve been so easily lured away, if I couldn’t say no to a stranger, how much harder must it be for women who actually know their abusers?

My life may have been very different because of my insecurity over a stranger’s judgement. I don’t like to think of what might have happened if my instincts didn’t take over. My door handle was missing. His plan was premeditated.

I may not have even survived the attack.

Or, I might have turned inward in my shame and away from the people I imagined that I had disappointed. I might have dropped out of school and abandoned my dream of becoming a doctor. I might have never been a wife or a mother. In a few short minutes, my life might have been ruined.

Over years of caring for patients, the truth about our shared humanity is so clear to me now. The difference between you and your chronically ill neighbor or the homeless person you carefully avoid eye contact with or the crazy cat lady next door is a lot less than it appears. Often the divisive factors arose in a moment in time beyond their control, when they suffered a heartbreak so deep that continuing with life as usual was no longer a possibility.

What did it take for Anne to heal? First, she had to overcome her undeserved shame that what happened to her was somehow her own fault. Was her dress too short? Could she have fought harder? Did she bring this on herself? She then had to get beyond her broken trust to find the courage to ask for help. This is real bravery. She knew that she was waking a sleeping monster that might take years, even a lifetime, to battle. And this was only the internal part of the fight.

Once she asked for help, Anne and I had to work together to figure out how to get it, not an easy task in a healthcare system with many barriers to mental health treatment. We needed perseverance and determination to connect her with the right people (who also took her insurance and didn’t have a 4 month long waiting list). It’s easy to imagine why people give up, some forever.

What can I possibly do with a problem so immense? It’s as simple as paying attention. When I see or hear something that doesn’t feel right, I will speak up. Because when we don’t stand up for our silent sisters, it sends them (and the world) the message that we don’t care. We accept it. We condone it. We are willing to live in a society with depressed mothers, anxious sisters, suicidal teenagers and teachers and daycare providers.

This is not the kind of world any parent would want to raise their daughters in.

This is not the kind of world I want my sons to grow up in.

 

Life and Death: Mothering and Doctoring

Harry and Ethel were always together.  My nurse, who liked to remind me that she began working at the clinic “before you were out of diapers,” couldn’t recall a single time that either of them had ever come to a doctors appointments without the other. “I guess they must really like each other,” she said after confessing that she sometimes made appointments to get away from her husband.

Harry and Ethel were active. They regularly attended ballroom dancing classes (“We’ll be going forever,” Harry joked with me at his last appointment.  “After 50 years, Ethel still hasn’t learned to let me take the lead.”) They were on a bowling team together and golfed in the summer. They traveled to faraway places. (“Harry likes adventures. I’d be fine with the Jersey shore,” Ethel told me once). They never seemed to tire of one another.

As a first year resident, still new at seeing my own patients, Harry and Ethel were two of my easiest. I looked forward to their visits. They only came to the office for check-ups since they were never really sick. They took no medications (except for multivitamins). They never complained.

So, I was surprised when I found out one Monday morning that Harry was admitted to the hospital. I asked around and discovered that he had slipped on the ice and broken a hip. I was relieved, but in hindsight I was also naive.

While a broken bone didn’t seem like a major medical problem to me that first year of residency (bones heal), I’d soon learn that a hip fracture in an elderly person was a very serious condition. I’d learn that there was a 5-8 fold increased risk of death in the first 3 months after a hip fracture. Of the survivors, only 1/2 would ever return to previous function while 20% would require long-term care.

But Harry’s fall was well before I knew any of that.

When I finished rounding on my morning patients, I went to visit Harry. Over the weekend he had an uncomplicated hip surgery so I found him in the General Medicine wing.

I was not surprised to see Ethel at Harry’s side, reading him a newspaper article. I asked Harry which resident was taking care of him and was happy to hear it was a 1st year colleague of mine. “You’re in good hands!” I said, and they both nodded.

In those early hospital days Harry was in good spirits. He couldn’t wait to get out of the hospital so he could take Ethel dancing. “You just wait to see my moves with this new hip,” he told her.

Rehabilitation was difficult, though. Harry wasn’t used to being immobile and certainly didn’t like being dependent on others. He was also in a lot of pain. The medications made him nauseous and sleepy, which caused him to lose weight and be even less cooperative with physical therapy.

As a new resident, I was very busy and didn’t have a chance to check in on him every day. So I was surprised when I snuck in to visit the next week at how pale and thin he looked. Ethel was trying to coax him to eat a treat she had baked for him that morning (“It’s his favorite!”) but Harry would have none of it.

I looked at Ethel, who was trying hard to be an optimistic cheerleader for her husband. Her eyes were puffy, and I was sure she had been crying. Deep furrows in her forehead appeared etched on her face since the last time I saw her. “He has always been a little stubborn,” she said, smiling at Harry.

Harry was uncharacteristically irritable. “Doc, they want me to go to inpatient rehab after this! Can’t I do these exercises on my own?” I looked to Ethel, who was shaking her head.

“You can’t even get up out of this bed without help,” she said to him. “You need to get stronger before you can think about coming home. Just do what the doctors say so we can both get out of here.”

2 days later my colleague told me that Harry had been transferred to intensive care. I was shocked.  I rushed through my lunch and headed down to the ICU to check on him before my afternoon patients.

I quietly knocked and stepped in to the room. Ethel was seated next to Harry, holding his hand and crying softly. Harry was asleep. I could hear his chest rattling from the doorway.

Ethel looked up and tried to smile, relieved at my arrival. There was so much hope in her eyes that I had to look away.

I sat down next to her. “What happened?” I whispered.

“The doctors say he has pneumonia,” she said, sniffling. Again, I was relieved. Pneumonia was very treatable.

“Well, I guess they’ve got him on strong antibiotics. He’ll be better in no time,” I said with more conviction than I felt as I looked from Ethel’s terrified face to Harry, lying motionless with tubes snaking from his body to the wall.

We sat together side by side in silence.  The only sounds in the room were the humming oxygen tank, Harry’s labored breathing and Ethel’s stifled sniffles. I tried not to look at the clock, though I was sure by now my first afternoon patient was probably waiting for me. Finally, I reached over and squeezed Ethel’s frail hand and told her I had to go. She nodded and thanked me for stopping by, but looked quickly away to shield me from her tears.

I would’ve lingered longer if I knew it was the last time I would see Harry. I might have tried to nudge him awake, and whisper in his ear. Harry, it’s me, just checking in on you. Fight harder. Don’t give up. Ethel needs you.

Harry died on an autumn day much too beautiful to die.

I had only been married to Paul for 5 years, and yet Ethel’s loss was unimaginable.

A few days later, on an equally beautiful day, my husband and I took our young sons apple picking. The sun was bright and the air was crisp and cool. It smelled like wet leaves and wood burning.

We parked our car at the farm stand across the street from the orchard. I steered Buster away from the entrance, knowing that apple cider donuts and pumpkin pie would be hard to resist and would defeat our intention to wear him out. Buster had an endless well of energy that caused Paul and I to collapse into bed at night.

IMG_3753.jpg

Buster, up in the trees where we often found him.

We crossed a broad field to get to the orchard. Buster scaled up and down trees while we chased after him, passing Digby back and forth between us. Before we knew it we had 2 big bags of apples, much more than our small family really needed. Paul and I were exhausted. Buster seemed even more energized.

I picked Digby up from the tall green grass where I had set him down while I arranged the overflowing apples so they wouldn’t fall out  during the trek back across the bumpy field. Digby was an easy child and would sit quietly wherever he was placed, as if to balance the ever-busy nature of his older brother.

IMG_3746

A rare protest from the usually tolerant Digby.

I left one of the bags on the ground for Paul and hoisted the other one up while swinging Digby back onto my hip with my free arm.

I walked cautiously, not wanting to trip with my arms full.  Suddenly Buster raced past me toward the farm stand. I heard a loud rumbling from my left and looked up to see an eighteen wheeler barreling down the road, much too fast. I opened my mouth to scream at Buster to stop, but nothing came out. He wouldn’t have heard me anyway.

I froze, my mouth wide open, apples in one arm, Digby in the other. My feet stuck to the ground as Buster raced toward the road and the truck flew toward the farm stand. I realized with horror that the truck wouldn’t be able to stop even if the driver saw the small child running right at it. They were going to collide.

Just as Buster reached the road a lanky teenager appeared out of nowhere and scooped him up into her arms. The truck driver whizzed past, oblivious that he had nearly destroyed my world.

Still, I couldn’t move.

The girl walked over to me and set Buster at my feet. I dropped the apples and set Digby back down on the grass. I reached out with trembling hands and pulled Buster close to me, my breath finally returning as his chest met mine. I buried my face in his curls, my heart beating wildly.

I stood up to thank the girl, but she was gone.

Had life always been so fragile and I was just too busy and tired to notice? I thought of all the times I envied the freedom of my childless colleagues. It was hard, this doctoring and mothering thing. But life without it was unthinkable.

As I squeezed Buster tight I vowed I would forever cherish this wild blessing the universe had given back to me.

IMG_3750

Birthday card adaptation of “Where the Wild Things Are,” featuring my wild thing Buster.

It Would Be Unwise

I started writing this post a little over a month ago, inspired by Reverend Jacqueline Lewis of Middle Collegiate Church in New York City.  She was one of two presenters speaking on “Spirituality and Medicine,” a lecture given at a medical conference I attended. I had no idea what to expect, but I was curious.

The first speaker was the renowned writer and Buddhist practitioner Steven Cope. He spoke eloquently about discovering one’s “dharma,” or true calling. Once determined, he urged, dharma should be pursued passionately without concern for the outcome. According to Cope, just the act of doing what we are driven in our hearts to do is rewarding regardless of the outcome. The joy is in the act of doing, even if we fail.

Reverend Lewis waited patiently onstage while Cope spoke, smiling and nodding in agreement. She looked a little nervous as she smoothed down her skirt and straightened her back. She was tall and beautiful, with smooth dark caramel skin, bright red lipstick and jet black braids. When it was finally her turn to speak, she leapt out of her seat.

Her voice was gentle but strong and she spoke with her whole body. Her braids flew around her shoulders as she danced across the stage passionately calling for love of self and others, preaching tolerance and inclusion to the all-white audience. On a large screen she projected slides of her church in action:  feeding the poor, marching at Gay Pride, laying on the floor of a government building to protest yet another black youth shooting.

She challenged us to disrupt the rampant racism in America. She implored us to imagine in our heads and our hearts what a world with no prejudice would be like.

She asked us to remember a time in our lives where we felt othered. A Jewish woman shared a story from her childhood of being pushed down in the mud by a group of boys for “killing Jesus.”  Even among our white crowd, it wasn’t difficult to remember a time of feeling othered – of being left out by not getting picked for a team, for being a girl or a Muslim or a gay man. The raw feelings of humiliation surfaced easily.

Then she asked us to step back and imagine a lifetime of this?  Imagine the pain of feeling ashamed every day.

As she spoke of peace and community, tears streamed down my cheeks. Her words touched me deeply.  I felt an intense connection with her, as if this black woman was my sister.

By the end of her talk, nearly every face shining back at her appeared ready to take up the cause. I know I was. This was weeks before the invasion of Charlottesville. Way back in a time when white America could still pretend that racism was not really a problem anymore.

Then the unthinkable happened. Worse, though, it was tolerated.

Why are we still fighting this demon? Genetically we are all so similar that the the very concept of race could be questioned.

I reached out recently to my black brother-in-law for some insight. He introduced me to a blog (abagond.wordpress.com) with some thought-provoking articles about race. In his blog post “Why whites are blind to their racism” Julian Abagond writes “America was founded on two crimes: taking the land of the red man and bringing the black man in chains to work it. To feel right and good about that whites had to be racist. They had to think of themselves as far better and more human than others.”

Our forefathers convinced themselves of their superiority so that their abhorrent actions would be acceptable. Otherwise, they would be evil. Although slavery no longer exists in America, oppression and racism clearly do. They are a necessary means to keep wealth in the hands of the (mostly white) elite. Blacks (among other minorities) are the others. They just can’t hide the color of their skin.

When we isolate ourselves in our safe white communities from people of other colors, religions, or beliefs we unintentionally propagate this otherness. And what we don’t know is scary.  I live in a homogenous, nearly all-white town. Despite my rational mind, I can’t deny my own fear when I find myself in an all-black neighborhood. Why?

At best we can hide from our racism and deny its very existence in us. I have done this most of my life. Our country knows what can happen at worst, as recently demonstrated. Racism is not new in America, but the current state of affairs in this country has emboldened haters into violent action. But are these just isolated events by extremists? Is racism really pervasive in every day living?

I asked my sister (who is happily married to a black man for nearly 2 decades) if she thought that racism in America was as bad as current events made it seem. Sadly, her answer confirmed what I had hoped in my heart wasn’t true. She told me that her family experienced racism “from the time we get up until the time we go to bed.” Every day.  Her husband concurred. Despite living in an ethnically diverse area, they are constantly vigilant about their personal safety and the safety of their two sons.

In another blog post (“All blacks are racist”) Abagond writes “When your life is shaped by the colour of your skin it is very hard not to see the world in terms of race. In fact, to be race-blind under such circumstances would be unwise.” Would be unwise. While I was warning my sons not to accept rides from strangers, black parents were teaching their sons to be careful about the ever-present danger of white people. To not instill this caution would be unwise given the alarming mortality statistics of black youths (not to mention their disproportionate representation in prisons).

IMG_7231.jpg

My sister and her beautiful family (Women’s March, DC)

Charlottesville was a horrific wake up call to me (and to much of the country). I realized that my strongly held beliefs about equality are meaningless if I keep them to myself. This won’t be easy. I strongly dislike confrontation. But I dislike inequality even more and I know it will not go away if we don’t challenge it. Silence is acceptance.

In his 1986 Nobel Peace Prize speech, Holocaust surviver Elie Wiesel said “We must always take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented.” We must always take sides.

Years ago my oldest son Buster attended a “Future Big Brother” class at our local hospital in preparation for the birth of my youngest son. The nurse leading the class handed him a black baby doll so he could practice being gentle. Although he was a wild and spirited boy, he took this training seriously and held the baby close.

The nurse said to him, “This baby is different than yours will be. Do you know why?”

Buster answered, “Because it isn’t real?”

The nurse laughed. “Well, I guess that’s true, but that isn’t what I was thinking.” She waited for him to answer.

After awhile he said, “Because it’s smaller?” The nurse shook her head.

“Because it has no hair?” She shook her head again. He didn’t want to disappoint her, so he kept guessing.

Finally, she said with a smile, “This baby is different than yours will be because it is black.” My son looked down again at the baby. He looked back at her.

His confused look said:  What difference does that make? Skin color was as insignificant as eye or hair color. His cousins were black.

The nurse looked flustered. I beamed.

I wish I could credit good parenting for his reaction but I know Buster’s response was a natural one for a child. Children aren’t born with prejudice. And as they grow up, exposure to different cultures can further protect them against developing it. It’s hard to hate black people if you have family members who are black. It’s hard to dislike Muslims if your best friend is one.

Hate is taught. But love can be taught, too.

Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that. (Martin Luther King)

So, how does this relate to healthcare?

Racism has to do with everything. It’s not just about hurling nasty words or violent actions. Racism is an insidious and deadly virus that stealthily invades and eats away at society, spreading to every facet of life from housing to healthcare.

I have never written a blog about the disparity in access to healthcare for the black population because I have very little personal experience. It never even occurred to me until I heard Reverend Lewis speak. Nearly all of my patients are white. But if I am being true to my mission to examine the problems in the American healthcare system (such as the lack of access, no insurance, preventable diseases that are not being prevented), I can’t ignore the importance of race.

Poor Americans have the worst health and 1 in 4 blacks are poor (versus 1 in 10 whites). Compared to whites, black people make 60% less money and have twice the rate of unemployment. They are less likely to own their homes or obtain higher education. Poor people also lack access to nutritious foods and are more likely to live in crowded and polluted areas. They lack access to open spaces.  All of these factors are predictors of health.

Even when poor people have insurance, they often can’t afford prescribed medications. Some of my poor patients have missed appointments with me because they couldn’t afford gas to get to there. Poor people can’t afford to miss work and they can’t afford childcare to come to the office after work. Obviously health outcomes are even worse for the uninsured (who are disproportionately black and Hispanic). In fact, there is a 40% increased risk of death for people without insurance. 40%!

Clearly blacks have enormous economic and social disadvantages compared to whites. Add to that the lack of access to healthcare and the result is a sick population.

There is also a negative impact on mental health and self-esteem for black children living in a world whose major institutions are run by whites. Black kids are constantly told in endless subtle and not-so-subtle ways by the entertainment industry and the news (and now by our government) that they are less important, less trustworthy, less deserving. Black is dark, evil and bad. White is pure and good.

Something has to change.

I believe change can happen when we see others as we see ourselves. This isn’t only a mental exercise, though. We have to step out of our comfort zones and embrace our brothers and sisters of different races and religions through our actions. We can intentionally immerse our families in different cultures. We can visit mosques, introduce ourselves to immigrant neighbors, celebrate Jewish holy days and slowly surround ourselves with others until we no longer notice any difference.

In my experience with difficult patients, even those I strongly disagree with, when I truly listen to their stories I can always find some common ground.  Even in the racists. Even in the misogynists. Sometimes I have to try harder to get past the rough exterior they have built up to ward off years of their own anger and shame.  But when I do, there is always some goodness.  I am forced to confront my own judgmental mind, and shift them out of the other category.

 

IMG_7903.jpg

 

I know I’m not unique. We all have capacity for empathy in us, we just need to remember it and sometimes to purposefully seek it out. After all, we have so much more in common with each other than we have differences.

I also know that much of my life I have been guilty of not speaking up. And although I am committing no acts of violence, my silence may be considered permission to those who would. I will try and follow the example of my courageous sister and summon the courage to find my voice. Even if it means confrontation. I carry her words with me as inspiration. “It starts with the people you love. I will always stick up for the side that is right.” And she does.

And so will I.  To not do so would be unwise.

I believe this is a part of my dharma.